Neonatal jaundice medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
The mainstay of treatment of patients with neonatal jaundice is phototherapy and blood exchange. | The mainstay of treatment of patients with neonatal jaundice is [[phototherapy]], [[intravenous]] [[immunoglobulins]] and [[Blood transfusion|blood exchange]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
* Phototherapy or blood transfusion are recommended by the American Academy of Pediatrics (AAP) for the treatment of neonatal jaundice.<ref name="AAP2004">{{cite journal |author=|title=Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation |journal=Pediatrics |volume=114 |issue=1|pages=297–316 |year=2004 |month=July |pmid=15231951 |doi= 10.1542/peds.114.1.297|url=http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=15231951 |author1= American Academy of Pediatrics Subcommittee on Hyperbilirubinemia}}</ref> | * Phototherapy or blood transfusion are recommended by the American Academy of Pediatrics (AAP) for the treatment of neonatal jaundice.<ref name="AAP2004">{{cite journal |author=|title=Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation |journal=Pediatrics |volume=114 |issue=1|pages=297–316 |year=2004 |month=July |pmid=15231951 |doi= 10.1542/peds.114.1.297|url=http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=15231951 |author1= American Academy of Pediatrics Subcommittee on Hyperbilirubinemia}}</ref> | ||
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===Phototherapy=== | ===Phototherapy=== | ||
* Phototherapy is considered as the safest intervention approach used in treatment of neonatal jaundice. | * Phototherapy is considered as the safest intervention approach used in treatment of neonatal jaundice. | ||
* Phototherapy showed its efficacy in lowering the level of the total serum bilirubin in all patients with neonatal jaundice regardless the underlying cause.<ref>{{cite journal |author=Amato M, Inaebnit D |title=Clinical usefulness of high intensity green light phototherapy in the treatment of neonatal jaundice |journal=Eur. J. Pediatr. |volume=150 |issue=4 |pages=274–6 |year=1991 |month=February|pmid=2029920 |doi= 10.1007/BF01955530|url=}}</ref><ref name="pmid15231986">{{cite journal| author=Ip S, Chung M, Kulig J, O'Brien R, Sege R, Glicken S et al.| title=An evidence-based review of important issues concerning neonatal hyperbilirubinemia. | journal=Pediatrics | year= 2004 | volume= 114 | issue= 1 | pages= e130-53 | pmid=15231986 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15231986 }}</ref> | |||
| | * Phototherapy also acts on preventing the rise of the bilirubin to the level of exchange transfusion threshold. <ref name="pmid19403502">{{cite journal| author=Newman TB, Kuzniewicz MW, Liljestrand P, Wi S, McCulloch C, Escobar GJ| title=Numbers needed to treat with phototherapy according to American Academy of Pediatrics guidelines. | journal=Pediatrics | year= 2009 | volume= 123 | issue= 5 | pages= 1352-9 | pmid=19403502 | doi=10.1542/peds.2008-1635 | pmc=2843697 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19403502 }}</ref> | ||
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==== Mechanism of phototherapy ==== | |||
* Phototherapy can lower the level of bilirubin in neonatal jaundice via the following mechanisms:<ref name="pmid3584465">{{cite journal| author=Ennever JF, Costarino AT, Polin RA, Speck WT| title=Rapid clearance of a structural isomer of bilirubin during phototherapy. | journal=J Clin Invest | year= 1987 | volume= 79 | issue= 6 | pages= 1674-8 | pmid=3584465 | doi=10.1172/JCI113006 | pmc=424499 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3584465 }}</ref> | |||
** Isomerization of bilirubin to lumirubin which is more soluble | |||
** Isomerization of bilirubin isomers to less toxic isomers (ex. 4Z and 15E) | |||
** Phototherapy converts bilirubin into soluble polar compounds by oxidation | |||
* Different sources of the light required for phototherapy: <ref name="pmid15686263">{{cite journal| author=Vreman HJ, Wong RJ, Stevenson DK| title=Phototherapy: current methods and future directions. | journal=Semin Perinatol | year= 2004 | volume= 28 | issue= 5 | pages= 326-33 | pmid=15686263 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15686263 }}</ref> | |||
** Home phototherapy | |||
** Sunlight exposure | |||
** Filtered sunlight | |||
** Fluorescent tubes | |||
** Halogen white light | |||
** Blue LEDs | |||
Exposing infants to high levels of colored light changes trans-bilirubin to the more water soluble cis-form which is excreted in the bile. Scientists studied 616 capillary blood samples from jaundiced newborn infants. These samples were randomly divided into three groups. One group contained 133 samples and would receive phototherapy with blue light. Another group contained 202 samples would receive room light, or white light. The final group contained 215 samples, and were left in a dark room. The total bilirubin levels were checked at 0, 2, 4, 6, 24, and 48 hours. There was a significant decrease in bilirubin in the first group exposed to phototherapy after two hours, but no change occurred in the white light and dark room group. After 6 hours, there was a significant change in bilirubin level in the white light group but not the dark room group. It took 48 hours to record a change in the dark room group’s bilirubin level. Phototherapy is the most effective way of breaking down a neonate’s bilirubin.<ref>{{cite journal |author=Leung C, Soong WJ, Chen SJ |title=[Effect of light on total micro-bilirubin values in vitro] |language=Chinese |journal=Zhonghua Yi Xue Za Zhi (Taipei) |volume=50 |issue=1 |pages=41–5 |year=1992|month=July |pmid=1326385 |doi= |url=}}</ref> | Exposing infants to high levels of colored light changes trans-bilirubin to the more water soluble cis-form which is excreted in the bile. Scientists studied 616 capillary blood samples from jaundiced newborn infants. These samples were randomly divided into three groups. One group contained 133 samples and would receive phototherapy with blue light. Another group contained 202 samples would receive room light, or white light. The final group contained 215 samples, and were left in a dark room. The total bilirubin levels were checked at 0, 2, 4, 6, 24, and 48 hours. There was a significant decrease in bilirubin in the first group exposed to phototherapy after two hours, but no change occurred in the white light and dark room group. After 6 hours, there was a significant change in bilirubin level in the white light group but not the dark room group. It took 48 hours to record a change in the dark room group’s bilirubin level. Phototherapy is the most effective way of breaking down a neonate’s bilirubin.<ref>{{cite journal |author=Leung C, Soong WJ, Chen SJ |title=[Effect of light on total micro-bilirubin values in vitro] |language=Chinese |journal=Zhonghua Yi Xue Za Zhi (Taipei) |volume=50 |issue=1 |pages=41–5 |year=1992|month=July |pmid=1326385 |doi= |url=}}</ref> | ||
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[[Category:Medicine]] | [[Category:Medicine]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Up-To-Date]] | [[Category:Up-To-Date]] | ||
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[[Category:Primary care]] | [[Category:Primary care]] | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
Revision as of 21:19, 4 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Overview
The mainstay of treatment of patients with neonatal jaundice is phototherapy, intravenous immunoglobulins and blood exchange.
Medical Therapy
- Phototherapy or blood transfusion are recommended by the American Academy of Pediatrics (AAP) for the treatment of neonatal jaundice.[1]
- It is recommended to treat the newborns with phototherapy or blood transfusion in order to decrease the risk of severe hyperbilirubinemia and kernicterus development.
Phototherapy
- Phototherapy is considered as the safest intervention approach used in treatment of neonatal jaundice.
- Phototherapy showed its efficacy in lowering the level of the total serum bilirubin in all patients with neonatal jaundice regardless the underlying cause.[2][3]
- Phototherapy also acts on preventing the rise of the bilirubin to the level of exchange transfusion threshold. [4]
Mechanism of phototherapy
- Phototherapy can lower the level of bilirubin in neonatal jaundice via the following mechanisms:[5]
- Isomerization of bilirubin to lumirubin which is more soluble
- Isomerization of bilirubin isomers to less toxic isomers (ex. 4Z and 15E)
- Phototherapy converts bilirubin into soluble polar compounds by oxidation
- Different sources of the light required for phototherapy: [6]
- Home phototherapy
- Sunlight exposure
- Filtered sunlight
- Fluorescent tubes
- Halogen white light
- Blue LEDs
Exposing infants to high levels of colored light changes trans-bilirubin to the more water soluble cis-form which is excreted in the bile. Scientists studied 616 capillary blood samples from jaundiced newborn infants. These samples were randomly divided into three groups. One group contained 133 samples and would receive phototherapy with blue light. Another group contained 202 samples would receive room light, or white light. The final group contained 215 samples, and were left in a dark room. The total bilirubin levels were checked at 0, 2, 4, 6, 24, and 48 hours. There was a significant decrease in bilirubin in the first group exposed to phototherapy after two hours, but no change occurred in the white light and dark room group. After 6 hours, there was a significant change in bilirubin level in the white light group but not the dark room group. It took 48 hours to record a change in the dark room group’s bilirubin level. Phototherapy is the most effective way of breaking down a neonate’s bilirubin.[7]
Phototherapy works through a process of isomerization that changes trans-bilirubin into the water-soluble cis-bilirubin isomer.[8][9]
In phototherapy, blue light is typically used because it is more effective at breaking down bilirubin (Amato, Inaebnit, 1991). Two matched groups of newborn infants with jaundice were exposed to intensive green or blue light phototherapy. The efficiency of the treatment was measured by the rate of decline of serum bilirubin, which in excessive amounts causes jaundice, concentration after 6, 12 and 24 hours of light exposure. A more rapid response was obtained using the blue lamps than the green lamps. However, a shorter phototherapy recovery period was noticed in babies exposed to the green lamps. Green light is not commonly used because exposure time must be longer to see dramatic results. Green light is not commonly used because it makes the babies appear sickly, which is disturbing to observers.
Ultraviolet light therapy may increase the risk of or skin moles, in childhood. While an increased number of moles is related to an increased risk of skin cancer,[10][11][12] it is not ultraviolet light that is used for treating neonatal jaundice. Rather, it is simply a specific frequency of blue light that does not carry these risks.
Increased feedings help move bilirubin through the neonate’s metabolic system.[13]
The light can be applied with overhead lamps, which means that the baby's eyes need to be covered, or with a device called a Biliblanket, which sits under the baby's clothing close to its skin.
Brief exposure to indirect sunlight each day and increased feeding are also helpful. A newborn should not be exposed to directsunlight because of the danger of sunburn, which is much more harmful to a newborn's thin skin than that of an adult.
If the neonatal jaundice does not clear up with simple phototherapy, other causes such as biliary atresia, PFIC, bile duct paucity, Alagille's syndrome, alpha 1 and other pediatric liver diseases should be considered. The evaluation for these will include blood work and a variety of diagnostic tests. Prolonged neonatal jaundice is serious and should be followed up promptly.
Exchange transfusions
Much like with phototherapy the level at which exchange transfusions should occur depends on the health status and age of the newborn. It should however be used for any newborn with a total serum bilirubin of greater than 428 umol/l ( 25 mg/dL ).[1]
References
- ↑ 1.0 1.1 American Academy of Pediatrics Subcommittee on Hyperbilirubinemia (2004). "Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation". Pediatrics. 114 (1): 297–316. doi:10.1542/peds.114.1.297. PMID 15231951. Unknown parameter
|month=ignored (help) - ↑ Amato M, Inaebnit D (1991). "Clinical usefulness of high intensity green light phototherapy in the treatment of neonatal jaundice". Eur. J. Pediatr. 150 (4): 274–6. doi:10.1007/BF01955530. PMID 2029920. Unknown parameter
|month=ignored (help) - ↑ Ip S, Chung M, Kulig J, O'Brien R, Sege R, Glicken S; et al. (2004). "An evidence-based review of important issues concerning neonatal hyperbilirubinemia". Pediatrics. 114 (1): e130–53. PMID 15231986.
- ↑ Newman TB, Kuzniewicz MW, Liljestrand P, Wi S, McCulloch C, Escobar GJ (2009). "Numbers needed to treat with phototherapy according to American Academy of Pediatrics guidelines". Pediatrics. 123 (5): 1352–9. doi:10.1542/peds.2008-1635. PMC 2843697. PMID 19403502.
- ↑ Ennever JF, Costarino AT, Polin RA, Speck WT (1987). "Rapid clearance of a structural isomer of bilirubin during phototherapy". J Clin Invest. 79 (6): 1674–8. doi:10.1172/JCI113006. PMC 424499. PMID 3584465.
- ↑ Vreman HJ, Wong RJ, Stevenson DK (2004). "Phototherapy: current methods and future directions". Semin Perinatol. 28 (5): 326–33. PMID 15686263.
- ↑ Leung C, Soong WJ, Chen SJ (1992). "[Effect of light on total micro-bilirubin values in vitro]". Zhonghua Yi Xue Za Zhi (Taipei) (in Chinese). 50 (1): 41–5. PMID 1326385. Unknown parameter
|month=ignored (help) - ↑ Stokowski LA (2006). "Fundamentals of phototherapy for neonatal jaundice". Adv Neonatal Care. 6 (6): 303–12. doi:10.1016/j.adnc.2006.08.004. PMID 17208161. Unknown parameter
|month=ignored (help) - ↑ Ennever JF, Sobel M, McDonagh AF, Speck WT (1984). "Phototherapy for neonatal jaundice: in vitro comparison of light sources". Pediatr. Res. 18 (7): 667–70. doi:10.1203/00006450-198407000-00021. PMID 6540860. Unknown parameter
|month=ignored (help) - ↑ Pullmann H, Theunissen A, Galosi A, Steigleder GK (1981). "[Effect of PUVA and SUP therapy on nevocellular nevi (author's transl)]". Z. Hautkr. (in German). 56 (21): 1412–7. PMID 7314762. Unknown parameter
|month=ignored (help) - ↑ Titus-Ernstoff L, Perry AE, Spencer SK, Gibson JJ, Cole BF, Ernstoff MS (2005). "Pigmentary characteristics and moles in relation to melanoma risk". Int. J. Cancer. 116 (1): 144–9. doi:10.1002/ijc.21001. PMID 15761869. Unknown parameter
|month=ignored (help) - ↑ Randi G, Naldi L, Gallus S, Di Landro A, La Vecchia C (2006). "Number of nevi at a specific anatomical site and its relation to cutaneous malignant melanoma". J. Invest. Dermatol. 126 (9): 2106–10. doi:10.1038/sj.jid.5700334. PMID 16645584. Unknown parameter
|month=ignored (help) - ↑ Wood, S. (2007, March). Fact or fable?. Baby Talk, 72(2).